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EMERGENCY CONTRACEPTION
Interest in emergency contraception
has grown considerably in the past
few years
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Adapted fromWHO/FRH/FPP/98.19
In April 1995, experts from around
the world met in Bellagio, Italy, and
produced a Consensus Statement on
Emergency
Contraception,
calling
on
providers to learn about the methods
and to make them available to all
women who may need them.
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Adapted from WHO/FRH/FPP/98.19

Later in 1995, seven organizations
involved
in
health
joined
Consortium
women’s
to
for
reproductive
form
the
Emergency
Contraception

p r g i l b e r t / v w -s e p 9 8
The aim to promoting access to the
method worldwide
4
Adapted from WHO/FRH/FPP/98.19

g i l b e r t / v w -s e p 9 8
The Consortium prepared a
resource pack containing
information and guidelines to
assist programme managers
5
Adapted fromWHO/FRH/FPP/98.19

g i l b e r t / v w -s e p 9 8
In December 1995, emergency
contraceptive pills (Yuzpe
method) was added to the
WHO model list of essential
drugs
6
Adapted from WHO/FRH/FPP/98.19
Who May Need Emergency Contraception
Any woman of reproductive age may need emergency
contraception at some point to avoid an unwanted
pregnancy, following situations such as:
 After voluntary sexual intercourse that took place
with no contraceptive protection
 After incorrect or inconsistent use of regular
contraceptive methods or when there has been an
accidental failure of other contraceptive methods

when a woman has been a victim of sexual assault
and has had no contraceptive protection.
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Method
or
User Failure
 condom breakage or slippage;
 miscalculation of the infertile period when using
periodic abstinence or failure to abstain from
sexual intercourse during the fertile days;
 expulsion of an IUD;
 failed coitus interrupts,
when ejaculation has
occurred in the vagina or on the external
genitalia;

failure to take oral contraceptives for more
than 3 days in a row;

being late for a contraceptive injection
p r g i l b e r t / v w -s e p 9 8
8
Methods of Emergency
Contraception

Increased doses of combined
oral contraceptives (COCs)
containing ethinylestradiol and
levonorgestrel (Yuzpe method)

High doses of progestogenonly pills containing
levonorgestrel

Copper-releasing IUDs.
9
p r g i l b e r t / v w -s e p 9 8
Adapted fromWHO/FRH/FPP/98.19

Emergency contraception differs in
many respects from regular
contraception. Providers need to
have clear guidelines on how and
when to offer emergency
contraceptives and they must give
clear instructions to clients in
order to avoid incorrect use or
confusion.
p r g i l b e r t / v w -s e p 9 8
10
Adapted fromWHO/FRH/FPP/98.19

g i l b e r t / v w -s e p 9 8
One
way
efficacy
of
of
expressing
the
emergency
contraceptives is to calculate
the treatment failure rate, i.e.
the number of women out of a
hundred who get pregnant in
spite of using an emergency
contraceptive method.
11
The failure rate of emergency
contraceptive pills ranges from 1
to 3 per hundred, and the failure
rate of copper IUDs is below 1 per
hundred.
12
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It
g i l b e r t / v w -s e p 9 8
has been suggested that
the efficacy of emergency
contra-ception be expressed
as
the
proportion
pregnancies
that
avoided
the
if
of
would be
method
is
used.
13
It has been calculated that
emergency contraceptive pills
prevent around 75% and copper
IUDs prevent more than 98% of
the pregnancies that would occur
if no emergency contraception
were used.
p r g i l b e r t / v w -s e p 9 8
14
Two emergency contraceptive pill regimens can be
used:


The
standard
regimen
consists
of
the
“combined” oral pills. This regimen is known as
the “Yuzpe method” and has been studied and
widely used since the mid 1970s.
When pills specially packed for emergency
contraception are available or when high-dose
pills containing 50 ug of ethinylestradiol and 250
ug levonorgestrel (or 500 ug dl-norgestrel) are
available:
two pills should be taken as the first dose as soon as
convenient but no later than 72 hours after unprotected
intercourse. These should be followed by two other pills
12 hours later.
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When only low-dose pills containing
30 ug ethinylestradiol and 150 ug
levonorgestrel (or 300 ug dl-norgestrel)
are available:

four pills should be taken as the first
dose as soon as convenient but no later than
72
hours
after
unprotected
intercourse.
These should be followed by another four pills
12 hours later.
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Emerging data indicate that an alternative
hormonal regimen consisting of levonorgestrelonly pills is equally effective as the Yuzpe
regimen but has a significantly lower incidence
of side-effects.
When pills containing 750
ug(0.75mg) levonorgestrel are available:

one pill should be taken as the first dose
as soon as convenient but no later than 72 hours
after unprotected intercourse. This should be
followed by another pill 12 hours later.
g i l b e r t / v w -s e p 9 8
17
When only mini-pills containing 30 ug
levonorgestrel are available:

twenty five pills should be taken as
the first dose as soon as convenient but no
later than 72 hours after unprotected
intercourse.
These should be followed by
second dose of twenty five other pills 12
hours later.
g i l b e r t / v w -s e p 9 8
18
When only mini-pills containing 75 ug
dl- norgestrel are available:

twenty pills should be taken as the
first dose as soon as convenient but no
later than 72 hours after unprotected
intercourse.
These should be followed by
second dose of twenty pills 12 hours later.
g i l b e r t / v w -s e p 9 8
19
 The
mechanism of action of
emergency contraceptive pills has
not
been
clearly
established.
Several studies have shown that
emergency contraceptive pills can
inhibit or delay ovulation. It has
also
been
suggested
that
emergency contraceptive pills may
prevent implantation by altering the
endometrium.
g i l b e r t / v w -s e p 9 8
20
Emergency contraceptive pills
do not interrupt pregnancy
and thus are not a form of
abortion.
21
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Efficacy
After a single act of unprotected sexual
intercourse, the Yuzpe regimen fails in
about 2 percent of women who use it
correctly (the chances of pregnancy are
approximately four times greater when
the
regimen
progestogen-only
is
not
used).
regimen
is
The
equally
effective (WHO, 1998).
g i l b e r t / v w -s e p 9 8
22

g i l b e r t / v w -s e p 9 8
If emergency contraceptive pills
were to be used frequently, the
failure rate during a full year of
use would be higher than that of
regular hormonal contraceptives.
This
is
just
one
reason
why
emergency contraceptive pills are
inappropriate for regular use.
23
Side-effects and their management

Nausea: Occurs in about 50 per cent of clients
using the combined emergency contraceptive pill
regimen but it does not usually last more than
24 hours. Nausea occurs in approximately 20
per cent of women using progestogen-only
emergency contraceptive pills.
Management:
Taking the pills with food or at
bedtime
help
may
reduce
nausea.
Prophylactic
administration of an anti-emetic has been shown to
reduce nausea in some women.
p r g i l b e r t / v w -s e p 9 8
24

Vomiting:
per
cent
of
Occurs in about 20
women
using
the
combined emergency contraceptive pill
regimen, and in about 5 percent of
those
using
progestrogen-only
emergency contraceptive pills.
Management:
If vomiting occurs within two
hours of taking emergency contraceptive pills,
the dose should be repeated. In cases of severe
vomiting, the repeat dose of the pills may be
administered vaginally.
g i l b e r t / v w -s e p 9 8
25
 Irregular uterine bleeding:
Some
women
after
may
experience
spotting
taking emergency contraceptive pills. The
majority
of
women
will
have
their
menstrual period of time or slightly early.
Management:
If there is a delay in
menstruation of more than one week, a
pregnancy test should be performed.
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
Other side effects:
tenderness,
fatigue.
headache,
breast
dizziness,
and
These side-effects do not
generally last more than 24 hours.
Management: Aspirin or another non-prescription
pain reliever can be used to reduce the discomfort
of headaches or breast tenderness.
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Eligibility
Criteria
The sole contraindication for the
use of emergency contraceptive
pills is pregnancy.
Emergency
contraceptive pills should
not be given to a woman who has a
confirmed pregnancy primarily because
they will not be effective.
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A.
Exclude the possibility that the client
may be pregnant by:

establishing the date of the last menstrual
period and whether it was normal;

establishing the time of the first and last
episodes of unprotected intercourse since
the last menstrual period to ensure that the
client is within the 72-hour treatment timeframe.
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B.
Other health assessments such
as
laboratory
tests,
pelvic
exam, etc., are not required
unless there is the possibility of
pregnancy.

These procedures can be offered as
part of routine reproductive health
care, if medically indicated or desired
by the client.
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Providers should take the
opportunity to ask if the client is
using a regular method of
contraception and to counsel her on
family planning options.
p r g i l b e r t / v w -s e p 9 8
31
Counselling
As
with
any
contraceptive
method,
emergency contraceptive pills should be
provided in a manner that is respectful of
the client and responsive to her needs
for information and care.
g i l b e r t / v w -s e p 9 8
32
Special Issues related to counselling

Stress - supportive atmosphere

Frequent Use - possibility of failure,
but no health risks

HIV and STDs - provides no protection

Counselling
about
FP
methods
-
opportunistic, but not a pre-requisite
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Information for the Client

Make certain that the client does not
want to become pregnant, and that
she understands that there is still a
chance
of
pregnancy
even
after
treatment
 Explain
how
to
take
emergency
contraceptive pills correctly
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Describe
Tell
common side effects
the client that drinking milk or
eating a snack with the pills may
help reduce nausea
Explain
that the dose needs to be
repeated if the client vomits within
two hours of taking emergency
contraceptive pills.
p r g i l b e r t / v w -s e p 9 8
35
 Advise
the
client
to
use
a
barrier
method such as the condom for the
remainder of her cycle.
 Explain
that
emergency
contraceptive
pills typically do not cause the client’s
menses to come immediately
 Advise
the client to come back or visit if
menstruation is delayed for more than
one week
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FOLLOW - UP
During the follow-up appointment

record the client’s menstrual data to
confirm that she is not pregnant (if in
doubt, perform a pregnancy test);

discuss
contraceptive
options,
as
appropriate

if
desired,
provide
a
contraceptive
method according to the woman’s choice
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If emergency contraceptive pills have failed and
the client is pregnant:
 advise her about other options and let her decide which
is most appropriate for her situation.
should be respected and supported.
Her decision
Refer the client to
other service providers as appropriate;
 reassure there is no evidence of any teratogenic effects
if the client decides to continue the pregnancy
 Emergency contraceptive pills are unlikely in themselves
to
increase
a
woman’s
risk
of
ectopic
pregnancy.
However, providers should be trained appropriately to
rule out the possibility of ectopic pregnancy in all cases
of emergency contraceptive pill failure
p r g i l b e r t / v w -s e p 9 8
38
Selecting a Product

Specially packaged for Emergency
Contraception
 Tetragynon/PC4,
Neo-Primovlar4/E-
Gen-C, or Fertilan (Yuzpe regimen)
 Postinor-2 (levonorgestrel)
39
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If specially packaged pills are not available:

4 pills of high-dose or 8 pills of low dose COCs
can
be
packed
in
suitable
containers
and
specially labelled for emergency contraception
use

A pill packet can be cut into strips of 4 pills of
high-dose or 8 pills of low-dose COCs and
dispensed in envelopes with instructions for use
as emergency contraception

Clients can be supplied with an entire packet of
COCs with instructions on how to use them for
emergency contraception.
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Initiating
after
the
regular
use
contraception
of
emergency
contraceptive pills
 CONDOMS can be used immediately
 DIAPHRAGMS can be used immediately
 SPERMICIDAL FOAM OR FILMS can be
used immediately
g i l b e r t / v w -s e p 9 8
41

ORAL CONTRACEPTIVES: started within
5 days of the beginning of the next menstrual
cycle (or according to the instructions for the
type of pill being used). Condoms till then.

INJECTABLE CONTRACEPTIVES: given
within 7 days of the beginning of the next
menstrual cycle. Condoms till then.

IMPLANTS: given within 7 days of the
beginning of the next menstrual cycle.Condoms
till then.
p r g i l b e r t / v w -s e p 9 8
42
 IUDs:
inserted
during
the
next
menstrual cycle. Condoms till then.
(If the client intends to use an IUD as long-term
method and meets IUD screening criteria,
emergency insertion of a copper-releasing IUD
may be an alternative to emergency
contraceptive pill use.
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 NATURAL
FAMILY PLANNING:
started after onset of menstruation
if
there
are
no
bleeding
irregularities. If this method is new
to the client, she should be given
counselling to ensure she knows how
to practise it correctly.
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 IMPLANTS:
given within 7
days of the beginning of the
next
menstrual
cycle.
Condoms till then.
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 STERILIZATION:
performed once
it is clear that this method has been
freely chosen and the client is fully
aware of the issues involved. Alternate
method of FP till then.
It is recommended that clients should be
discouraged from making this decision under the
stressful conditions that typically surround
emergency contraceptive pill use.
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Dealing with Common Concerns
Misconception 1

Emergency contraception is a form of
abortion.
This is not so. Emergency contraception
methods work in a variety of ways to
prevent pregnancy depending on when in the
menstrual cycle they are used. They do not
displace an implanted embryo, and cannot
terminate an established pregnancy
p r g i l b e r t / v w -s e p 9 8
47
Misconception 2
Emergency
contraception
promotes
irresponsible and/or promiscuous sexual
behaviour.
There are no data to suggest that the
use of emergency contraception leads to
irresponsible and/or promiscuous sexual
behaviour.
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Emergency
contraception
can
act
a
bridge to contraceptive information and
counselling for regular use and as an
opportunity to provide information on
prevention
of STDs and
HIV/AIDS.
This is particularly valuable in the case
of young people who may first contact a
health service because of the need of
emergency.
49
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Misconception 3
Emergency
contraception is targeted
mainly at unmarried adolescents and
may undermine parental authority and
community morals.
Women of all ages may need emergency
contraception and adolescents are not
the only target group.
50
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Young
women with little contraceptive
knowledge and experience are at specially high
risk of an unwanted pregnancy, and preventing
pregnancy in adolescents is a high priority in
all countries.
Parents of adolescents should also be aware
of the existence of emergency contraception
because they may be willing to advise their
youngsters on this option if they confide in
them about their sexual relations.
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Misconception 4
Women or couples
may
stop
using
regular
contraception if emergency contraception is easily
available.
The information given to clients about emergency
contraception should clearly state that is is
meant
only
for
“emergency”
situations.
The
efficacy of emergency contraceptive pills is lower
than that of the regular use of combined pills
and is associated with unpleasant side-effects
such as nausea and vomiting.
p r g i l b e r t / v w -s e p 9 8
52

repeated use of emergency
contraceptive pills in any month
can expose women to higher doses
of steroids than those

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recommended during one cycle.
emergency contraceptive pills are
more expensive than regular use of
oral contraceptives.
53
Misconception 5
 Men may be less willing to use condoms if
they know that their partners can use
emergency contraception.
Couples
use
pregnancy
condoms
and
the
to
prevent
transmission
both
of
disease. Emergency contraception does
not protect against STDs, including HIV.
54
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
The use of emergency contraceptive pills
is associated with side effects that can be
avoided if condoms are used instead.

Couples may be more willing to rely on
condoms for contraception and protection
against STD/HIV infection if they know
that emergency contraception is available as
a back-up in the case of condom failure
during intercourse such as a breakage or
slippage.
55
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